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Community interventions for preventing smoking in young people

  1. Kristin V Carson1,*,
  2. Malcolm P Brinn1,
  3. Nadina A Labiszewski1,
  4. Adrian J Esterman2,
  5. Anne B Chang3,
  6. Brian J Smith4

Editorial Group: Cochrane Tobacco Addiction Group

Published Online: 6 JUL 2011

Assessed as up-to-date: 18 FEB 2011

DOI: 10.1002/14651858.CD001291.pub2


How to Cite

Carson KV, Brinn MP, Labiszewski NA, Esterman AJ, Chang AB, Smith BJ. Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD001291. DOI: 10.1002/14651858.CD001291.pub2.

Author Information

  1. 1

    The Queen Elizabeth Hospital, Clinical Practice Unit, Adelaide, South Australia, Australia

  2. 2

    University of South Australia, Adelaide, South Australia, Australia

  3. 3

    Charles Darwin University, Menzies School of Health Research, Casuarina, Northern Territories, Australia

  4. 4

    The Queen Elizabeth Hospital, Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia

*Kristin V Carson, Clinical Practice Unit, The Queen Elizabeth Hospital, 4A Main Building, 28 Woodville Road Woodville South, Adelaide, South Australia, 5011, Australia. kristin.carson@health.sa.gov.au.

Publication History

  1. Publication Status: Edited (no change to conclusions), comment added to review
  2. Published Online: 6 JUL 2011

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

 
Summary of findings for the main comparison. Community interventions for preventing smoking in young people

Community interventions for preventing smoking in young people

Patient or population: patients with preventing smoking in young people
Settings:
Intervention: Community interventions

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlCommunity interventions

Weekly smoking
Follow-up: 2- to 15-years
Study populationOR 0.83
(0.59 to 1.17)
17508
(7 studies)
⊕⊝⊝⊝
very low1,2,3

169 per 1000144 per 1000
(107 to 192)

Medium risk population

170 per 1000145 per 1000
(108 to 193)

Monthly smoking
Follow-up: 2- to 15-years
Study populationOR 0.97
(0.81 to 1.16)
27077
(9 studies)
⊕⊝⊝⊝
very low1,2,3

148 per 1000144 per 1000
(123 to 168)

Low risk population

140 per 1000136 per 1000
(116 to 159)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval OR: Odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 A mixture of RCT's and CCT's were used, lack of allocation concealment, blinding and significant loss to follow-up
2 Significant heterogeneity as determined by a combination of visual data inspection and I-squared statistic.
3 Some studies required manual adjustment for clustering effects as this was not addressed by the original study authors

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

The reduction of smoking prevalence among adolescents remains a key public health priority (BMA 2008). Addiction to nicotine usually begins during adolescence although the proportion of new smokers who first use cigarettes after the age of 18 has increased in the United States from around 25% in 2002 to 40% in 2009 (SAMHSA 2009). An estimated one-in-five young teenagers already smokes regularly and another 30 million children throughout the world will take up the habit every year (GYTSC 2002) with 19.1% of school students who had never smoked cigarettes indicating that they would initiate smoking within the next year (MMWR 2008). In England the prevalence of regular smoking amongst 11 to 15 year olds in 2009 was 6%, a decline from 13% in 1996 (NHS IC 2010). Amongst 15 year olds the prevalence was higher in girls (16%) than boys (14%) (NHS IC 2010). Current reports still indicate that globally, smoking behaviour among adolescent girls is increasing over that of boys (Mackay 2006; Warren 2009). The UMDNJ 2007 New Jersey Youth Tobacco Survey estimates that 90 million cigarettes, or 4.2 million packs of cigarettes were consumed by high-school students annually in 2006.

There is a wide-held theory that if smoking does not start during adolescence, it is unlikely ever to occur (USDHHS 1994). This has resulted in various attempts to reduce the number of young people taking up smoking through primary prevention programmes, which have been designed to discourage experimentation with cigarettes and to deter regular use. Most interventions have included prevention programmes delivered in school settings, however the results have been mixed and reported effects small (Rooney 1996, Wiehe 2005, Thomas 2006). Mass media interventions have been compared in another Cochrane review, Brinn 2010 also with mixed results. The most effective campaigns for the review (Brinn 2010) were based on solid theoretical grounds, used formative research in designing the campaign message, and the message broadcasts were of reasonable intensity over extensive periods of time. Recognition that decisions to smoke are made within a broad social context has led to the development and implementation of community-wide programmes. Such interventions are based on the premise that social and environmental processes impact upon health and well-being and contribute to health decline, disease, and mortality. It has been argued that the essence of the community approach to influence smoking behaviour, in particular smoking prevention lies in its multi-dimensionality, in the co-ordination of activities to maximise the chance of reaching all members, and in ongoing and widespread support for the maintenance of non-smoking behaviour (Schofield 1991).

Interventions with multiple components such as age restrictions for tobacco purchase, tobacco-free public places, various mass media communications and special programmes in schools are often combined to create large-scale community-wide initiatives, to influence the smoking behaviour of young people. Initiatives vary in the extent to which they emphasise community involvement in problem specification and planning of the intervention. Some have been conducted through community groups and organisations emphasising a principle of 'ownership' or 'partnership' in promoting health. Community members are involved in decisions about the implementation of various activities within the programme, often building on existing organisational structures.

Despite the potential of community-wide programmes, debate continues about their effectiveness in influencing the smoking behaviour of young people. For example, a non-systematic review of eighteen smoking prevention programmes up to 1995 concluded that community initiatives have yet to demonstrate that they can directly reduce smoking prevalence in adolescents (Stead 1996).

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

To carry out a systematic review to assess the effectiveness of community interventions in influencing the smoking behaviour of young people. In particular the following issues were addressed:

a. The effectiveness of community interventions, compared with no intervention in influencing the smoking behaviour of young people;

b. The effectiveness of community interventions compared with other single component interventions (e.g. school-based programmes) in influencing the smoking behaviour of young people.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We considered studies using one of the following designs: 

a. RCT: (randomized controlled trials) in which participants were assigned prospectively to one or more alternative forms of intervention using a process of random allocation;

b. CCT: (controlled clinical trials) in which participants were assigned prospectively at the level of community, geographical region or school, to one or more alternative intervention groups using a quasi-random allocation method, or in which the method of assignment was unclear but could possibly have been random or quasi-random;

c. CBA: (controlled before-and-after trial) where contemporaneous baseline and post-intervention data was collected from the intervention group and a comparable population, (no CBA studies were identified for inclusion in this review).

Each study needed to have a minimum of two clusters in each of the intervention and control groups.

Studies which did not report baseline characteristics were excluded.

 

Types of participants

Young people aged less than 25 years.

 

Types of interventions

Interventions were considered which:

a. were targeted at entire or parts of entire communities or large areas, and;

b. had the intention of influencing the smoking behaviour of young people, and;

c. focused on multi-component (i.e. more than one) community intervention, which could include but was not limited to: school-based programmes, media promotion (e.g. TV, radio, print), public policy, organisational initiatives, health care provider initiatives, sports, retailer and workplace initiatives, anti-tobacco contests and youth anti-smoking clubs.

Community interventions were defined as coordinated widespread (multi-component) programmes in a particular geographical area (e.g. school districts) or region or in groupings of people who share common interests or needs, which support non-smoking behaviour.

Studies which only included single component interventions, did not have community involvement (e.g. school-based only) or had mass media as the sole form of intervention delivery were excluded.

 

Types of outcome measures

Young people were classified as smokers or non-smokers in different ways according to daily, weekly or monthly frequency of smoking, or by lifetime consumption. Where possible the strictest distinction was used, in which youths with any history of cigarette use were defined as smokers.

 

Primary outcomes

The primary outcome measure of smoking behaviour were objective (e.g. saliva thiocyanate levels, alveolar carbon monoxide) or self-reported smoking. This outcome was measured in terms of:

a) the level of change in smoking behaviour observed,

b) the sustainability of the change in behaviour after the intervention ('less than' versus 'longer than' one year).

 

Search methods for identification of studies

Possible studies were identified from the Cochrane Tobacco Addiction Group Database which includes reports of possible trials identified from regular searches of CENTRAL, MEDLINE, EMBASE and PsycINFO (see search strategies and dates in the Tobacco Addiction Group Module). Additional searches covered a wider range of databases and combined terms related to smoking, young people and community-wide interventions.

 

Electronic searches

For this update searches were limited by publication date from 2002 onwards. The search platform is that used for the present update. The following databases were searched:

Searched via OVID on 18th August 2010: Medline, EMBASE, PsycINFO, Econlit.
Searched via CSA on 19th August 2010: Sociological Abstracts, British Humanities Index, PAIS, ERIC, ASSIA.
Searched in the Cochrane Library issue 3, 2010: Cochrane Central Database of Controlled Trials (CENTRAL)

Other databases searched for the original review were no longer easily available, and since no original studies had been located solely from one of these sources we did not update these searches. Databases searched for earlier versions are listed in Appendix 1

The MEDLINE strategy is listed below. Other strategies are provided in the Appendix

1     exp Smoking/
2     "Tobacco Use Disorder"/ or Tobacco/
3     (smoking or tobacco or cigarette$).ti,ab.
4     1 or 2 or 3
5     (young adj people).ti,ab,sh.
6     (children or juveniles or girls or boys or teenagers or adolescents).ti,ab.
7     Adolescent/
8     Child/
9     minors.ti,ab,sh.
10     8 or 6 or 7 or 9 or 5
11     (nationwide or statewide or countrywide or citywide).ti,ab,sh.
12     (nation adj wide).ti,ab,sh.
13     (state adj wide).ti,ab,sh.
14     ((country or city) adj wide).ti,ab,sh.
15     outreach.ti,ab,sh.
16     (multi adj (component or facet or faceted or disciplinary)).ti,ab,sh.
17     (field adj based).ti,ab,sh.
18     (interdisciplinary or (inter adj disciplinary)).ti,ab,sh.
19     local.ti.
20     citizen$.ti,ab,sh.
21     (community or communities).mp.
22     11 or 21 or 17 or 12 or 20 or 15 or 14 or 18 or 13 or 16 or 19
23     22 and 4 and 10

 

Searching other resources

The bibliographies of papers identified in the electronic searches were checked for any additional relevant studies, and personal contact with content area specialists were made.

 

Data collection and analysis

 

Selection of studies

From the title, abstract, or descriptors, KC independently reviewed the literature searches to identify potentially relevant trials. All studies that clearly did not meet the inclusion criteria in terms of study design, population or interventions, were excluded. All potential inclusions and 'exclude but relevant' studies were confirmed by a second author (MB).

 

Data extraction and management

One review author (KC) completed data extraction for each included study, which was reviewed by an additional author (either MB or NL) using a tailored standardised data extraction form. All disagreements were resolved by consensus.

 

Assessment of risk of bias in included studies

The quality of included studies were assessed using the ‘Risk of bias’ tool described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008) and additional criteria developed by the Cochrane EPOC Group (EPOC 2009). One review author (KC) independently assessed the risk of bias for each included study, which was independently assessed again by one of two additional authors (MB or NL). All disagreements were resolved by consensus. Risk of bias was assessed with the following seven domains: sequence generation; allocation concealment; blinding of participants and outcome assessors; incomplete outcome data; selective outcome reporting; and other potential threats to validity (Higgins 2008). Three additional domains were included that assessed design-specific threats to validity including: imbalance of outcome measures at baseline; comparability of intervention and control group characteristics at baseline; and protection against contamination (EPOC 2009). Finally, for cluster study designs, we assessed the risk of bias associated with an additional domain; selective recruitment of participants. In studies eligible for inclusion in this review, the term ‘participant’ may refer to schools, community organisations and individual young people.

 

Measures of treatment effect

Outcomes

Outcome measures for RCT, CCT and CBA studies were selected in accordance with Cochrane Collaboration standards (Higgins 2008) for dichotomous outcomes, continuous outcomes (mean difference) and counts or rates (rate ratio).

 

Unit of analysis issues

Studies found to contain unit of analysis errors were re-analysed if data were available. Unit of analysis errors are found in studies that allocate participants to treatment or control in clusters (e.g. schools and communities), but analyse the results by individual participants. This can result in overestimation of the statistical significance of the results by not accounting for the clustering of individuals in the data (Rooney 1996; Ukoumunne 1999). For studies that did not include adjustments for clustering the size of the trial was reduced to the effective sample size (Rao 1992) using the original sample size from each study, divided by a design effect of 1.2 which is consistent with other smoking cessation community intervention trials (Gail 1992) and as per recommendations in the Cochrane Handbook, section 16.3.4 (Higgins 2008).

 

Dealing with missing data

Where statistics essential for analysis were missing (e.g. group means and standard deviations for both groups are not reported) and can not be calculated from other data, we attempted to contact the authors to obtain data.

 

Assessment of reporting biases

Potential reporting biases would have been assessed using a funnel plot, providing the inclusion of greater than ten studies for each reported outcome. Asymmetry in the plot could be attributed to publication bias, but may well be due to true heterogeneity, poor methodological design or artefact. As there were fewer than ten studies for each outcome, the reporting biases have been extrapolated within the 'other bias' section in the risk of bias tables.

 

Data synthesis

Meta-analyses were only conducted if relevant, valid data were available from at least two studies of the same design, with interventions that were conceptually similar (e.g. interventions that include school components) and measured the same outcome. The fixed-effects model was used for meta-analysis with the exception of data presenting significant heterogeneity as determined by a combination of the I² statistic (> 60%) and visual inspection of the data. In such instances the analysis was converted to the random-effects model.

For smoking behaviour outcomes entered in a meta-analysis we used outcomes reported at the longest follow up. Studies that reported a follow up at less than 12 months and after a longer period could be included in both time periods in the sub group analysis by duration of follow up. For studies with multiple outcome measures that were appropriate for inclusion in a meta-analysis, the authors ranked the effect sizes of each measure and used the median value. Where two appropriate measures were used, the most conservative value was taken.

A tabular analysis considering the direction of observed effects and size for each study outcome is presented in Additional tables. A narrative synthesis was also conducted taking into consideration the methodological quality of each study (Results).

 

Subgroup analysis and investigation of heterogeneity

The effects of community interventions are complex, and may be influenced by a number of competing factors. Significant heterogeneity relating to results and study characteristics was determined by a combination of the I² statistic (> 60%) and visual inspection of the data as per recommendations in the Cochrane handbook, chapter 9.5.4 (Higgins 2008). We were unable to use a Forrest plot for visual inspection of the data due to an insufficient number of included studies for the reported outcomes. We conducted sub-group analyses to further investigate the different aspects of community intervention programmes. Subgroup analyses were conducted only if comparable data (as outlined above) was available from two studies, which could be considered similar enough to be included in the same subgroup, (e.g. two studies conducted in rural areas), or reporting separate outcomes for different subgroups (e.g. by gender). The following characteristics were pre-specified for possible sub-group analysis prior to data extraction:

a) Population - e.g. developed/developing countries or urban/rural populations

b) Subjects - e.g. gender, age or socioeconomic status

c) Intervention - e.g. number of intervention components, duration of interventions or intensity of interventions

d) Design - e.g. duration of follow-up

 

Sensitivity analysis

Sensitivity analysis was conducted on studies with a high risk of bias for sequence generation and allocation concealment.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms
 

Description of studies

See: Characteristics of included studies and Characteristics of excluded studies tables

 

Results of the search

Reports relating to twenty five studies met all of the inclusion criteria from 2717 articles (see Figure 1 for PRISMA diagram). Detailed information about each included study is provided in the 'Characteristics of included studies' table. (See 'Characteristics of excluded studies' for details of the sixty eight excluded studies and reasons for exclusion.) All of the included studies used a controlled trial design with clustering.

 FigureFigure 1. Flow diagram of literature for this review

 

Included studies

All 25 studies investigated the effects of multi-component community interventions directed at young people, <25 years, using either a parallel group RCT (n=15) or CCT (n=10) design. Trials were published between 1989 and 2009, though the methodology and preliminary results for some studies were published earlier; from 1983. A total of approximately 104,000 participants were recruited from a mixture of schools (n=735), community clubs (n=92), communities/cities/towns n=49 and paediatric practices (n=12). Seventeen studies originated from the United States of America, three from Australia, two from the United Kingdom and one each from India and Finland. One study (De Vries 2003) included six countries (Denmark, Finland, Netherlands, Portugal, Spain and the United Kingdom) as a nested, cluster controlled clinical trial.

 

Characteristics of communities:

The communities in which the interventions took place varied across the studies. For example, in one study the populations of the communities randomised ranged from 1,700 to 13,500 (Biglan 2000) and another was based in a city of 1.3 million people (Pentz 1989), while the largest study spanned six countries (De Vries 2003). Some communities were in rural areas (Biglan 2000; Hancock 2001) whilst others were in towns or cities in predominantly urban areas (Winkleby 1993; Perry 1994; Piper 2000) and some communities were specifically targeted because of economic deprivation (St Pierre 1992; Perry 2008).

 

Characteristics of participants:

The participants varied across studies. Some studies targeted young people in specific high-risk groups; for example those defined as high-risk because they lived in a deprived area (St Pierre 1992; Perry 2008), because they attended a continuation high-school (continuation high-schools are alternative high-schools in the USA for young people at risk of dropping out of the school) (Sussman 1998; Winkleby 2004), or because they were expected to have a high smoking prevalence (Elder 2000). Native American children living on reservations were targeted in one study (Schinke 2000). The age of participants ranged from 8 to 24 years across the different studies. The age of targeted participants also varied and ranged from 10 to 24 years of age.

 

Characteristics of interventions:

The interventions evaluated in the 25 studies were diverse and each differed in the focus of activity. Thirteen focused specifically on influencing youth smoking behaviour through tobacco prevention initiatives (St Pierre 1992; Gordon 1997; Tang 1997; Sussman 1998; Biglan 2000; Elder 2000; Piper 2000; Schinke 2000; Stevens 2002; Schofield 2003; Gordon 2008; Perry 2008; Klein 2009), five included tobacco prevention with an additional aim to reduce specific health risk factors for cancer (Hancock 2001) or cardiovascular disease (Winkleby 1993; Perry 1994; Baxter 1997; Vartiainen 1998), while the remaining seven studies combined goals through a combination of tobacco prevention with either reduction or cessation initiatives (Pentz 1989; Murray 1994; D'Onofrio 2002; De Vries 2003; Perry 2003; Winkleby 2004; Hawkins 2009). Though the interventions for all studies involved influencing smoking behaviour, nine studies also included interventions for alcohol, (Elder 2000; Stevens 2002) alcohol and marijuana (Schinke 2000) or alcohol, marijuana, other drug use and/or delinquent behaviour (Pentz 1989; St Pierre 1992; Sussman 1998; Piper 2000; Stevens 2002; Perry 2003).

The extent to which attempts were made to include community participation also varied significantly. In five studies community leaders were encouraged to become actively involved in both the development and in giving ongoing support for the community programmes (Perry 1994; Piper 2000; Hancock 2001; Perry 2003; Hawkins 2009), though the duration and intensity of involvement differed. In the 'Age Appropriate' arm of the Piper 2000 study a community organiser was employed for six months over a three year period whilst in the 'Intensive' arm the organiser was employed for one fifteen month block. They were trained to use survey data, prioritise and target risk factors for prevention actions and to choose which prevention policies and programmes addressed the communities needs. However, in the Perry 2003 study, eight community organisers were hired to create and facilitate extra-curricular activities for the second component of the D.A.R.E. intervention. In the study by Hawkins 2009, community leaders received six training sessions delivered over six to twelve months to form a community coalition of diverse stakeholders to implement and monitor the intervention. Other studies involved multiple organisations including the national health service, city councils, social workers, business owners, voluntary organisations, sports organisations, health care providers, community organisations, media, retailers, schools, government, law enforcement or workplaces.

 
Specific intervention components:

The majority of studies included school components in addition to a multi-component community intervention (twenty one of the twenty five included studies), though the duration and intensity differed. As examples, Biglan 2000 had five class sessions over a one week period for three consecutive years, and Hawkins 2009 allowed schools to choose any combination of school and community programmes which ranged from five, two-hour weekly sessions to weekly, year-long classroom activities; Pentz 1989 included ten school and homework sessions per year over two years, while D'Onofrio 2002 only included an optional activity to conduct a tobacco survey at school as part of an intervention run through local community 4-Health Clubs. This intervention included education, booklets, worksheets, puzzles, stories, experiments, poster and activities to make a anti-smoking commercial at 4-Health Clubs. One other trial conducted an intervention with local girls' and boys' Clubs St Pierre 1992 including education, group activities and video sessions, however no school-based interventions were included. In total four studies included no school related activities (St Pierre 1992; Elder 2000; Stevens 2002; Klein 2009). The remaining three studies involved: recruitment from a migrant education programme with an intervention focusing on parent/child communications with eight weeks of evening group meetings plus booster sessions (Elder 2000); Stevens 2002 enrolled subjects from a paediatric primary care setting, where the family would decide upon a personal tobacco prevention policy with the addition of subsequent clinician education visits, twelve mail out newsletters specific to adults and twelve specific to young people in addition to letters from their respective clinician. Finally the Klein 2009 intervention focused on the government initiated 'Clean Indoor Air' policy as their programme, with an evaluation of the subsequent smoking ban in public places, particularly in restaurants, cafes and bars.

Optional extracurricular projects were added to some interventions including organisation of a tobacco-free day and the option of working with community agencies on tobacco use prevention (D'Onofrio 2002), non-smoking conference attendance on National non-smoking day (De Vries 2003), health fairs, after-school clubs and amusement park activities (Gordon 2008), promotion of World No Tobacco Day (Schofield 2003), drug-free parties and drug-awareness week (Sussman 1998), amongst others (Hancock 2001; Perry 2003). Four studies used incentives for completion of tobacco prevention assignments and to improve class attendance (Piper 2000; Stevens 2002; Schofield 2003; Gordon 2008).

Sixteen trials involved parent/guardian participation which mainly included education through pamphlets or homework requiring parent/guardian involvement (Gordon 1997; Biglan 2000; Piper 2000; Hancock 2001; D'Onofrio 2002; Perry 2003; Schofield 2003; Perry 2008; Gordon 2008; Hawkins 2009). Though some studies did have stronger parental involvement with equal parent/youth attendance for group sessions (Elder 2000; Stevens 2002), requests or incentives to quit smoking as a role model (De Vries 2003; Tang 1997), or attendance at tobacco prevention information sessions (Pentz 1989; Schinke 2000). Ten studies included peers as role models, (Baxter 1997; Vartiainen 1998; Biglan 2000; Elder 2000; Piper 2000; Perry 2003;Schinke 2000; Schofield 2003; Perry 2008;Winkleby 1993), two of which used older high-school students (Winkleby 1993; Schinke 2000). Four studies were simultaneously run with adult programmes (Winkleby 1993; Perry 1994; Baxter 1997; Vartiainen 1998).

Media advocacy components were included in nine studies, two of which included television prevention initiatives (Pentz 1989; De Vries 2003) in addition to other media. The remaining seven studies used a combination of local media publications, magazines, radio, flyers, posters and newspapers (Winkleby 1993; Perry 1994; Tang 1997; Biglan 2000; Piper 2000; Schinke 2000; Hancock 2001).

Six interventions aimed at young people included components focusing on reducing tobacco scales to minors. Some included specific activities for youth to reduce illegal tobacco sales, (Biglan 2000; De Vries 2003; Schofield 2003; Winkleby 2004) whilst the study by Gordon 1997 reminded tobacco retailers about the law before conducting retailer tests where young people attempted to purchase tobacco products. Another study (Tang 1997) provided retailer education and surveillance.

Health care professionals as intervention deliverers were a key component in four studies and a smaller component of interventions in four other studies. The study by Stevens 2002, used the paediatric primary care setting to recruit youth and implement the intervention via family/clinician meetings through individualised development of a smoke-free policy, for each family. Other studies included training for pharmacists and dental care interventions (De Vries 2003), continuing education and utilisation of health professionals (Perry 1994; Hancock 2001), or simply provided health education through intervention components such as mass media and other health promotion activities (Pentz 1989; Piper 2000; Schofield 2003; Winkleby 2004). Further encouragement into healthy life-style choices through smoke-free sporting events such as roller-skating, rock climbing, bowling, snowboarding, skiing, disc golf tourneys and skateboarding competitions, were also aspects to the Sussman 1998, De Vries 2003 and Gordon 2008 studies.

 
Specific control components:

Most studies used usual activities as the control groups (Baxter 1997; Tang 1997; St Pierre 1992; Winkleby 1993; Murray 1994; Perry 1994; Sussman 1998; Vartiainen 1998; Piper 2000; Schinke 2000; Hancock 2001; D'Onofrio 2002; De Vries 2003; Schofield 2003; Gordon 2008; Klein 2009; Hawkins 2009), though two studies included minimal interventions which included components to influence youth smoking behaviour - Biglan 2000 opted to invest the same intensity and duration for the programme, where the intervention focused on drug use prevention, and Gordon 1997 provided control students with smoking prevention booklets which were used in schools, plus take home workbooks. Retailers were also tested for underage cigarette purchases in the control catchment areas through students attempting purchases. Three control areas were provided with delayed interventions, which were commenced after the evaluation period for the studies were completed (Pentz 1989; Perry 2003; Perry 2008). One study (Schofield 2003) offered the intervention to control schools after completion of the evaluation only if the schools requested it, however support was offered for other health related issues during the evaluation period. Other initiatives unrelated to smoking were used as controls in some studies to account for biases associated with increased resources and attention provided to intervention subjects, or as an alternative means of providing some form of benefit to the control clusters for their participation in the evaluation. The control group in Elder 2000 consisted of a first aid and home safety education programme focused on preparation for emergencies, skills and household safety concerns such as baby-proofing a house. Education, role-playing sessions and intensity of the programme mimicked that of the smoking prevention intervention. In Winkleby 2004 school students learned about drug and alcohol abuse prevention through a modified version of Project Toward No Drug abuse, (Sussman 1998) focusing on health motivation, social skills and decision making regarding drug and alcohol use.

 
Intervention delivery:

Methods for the programme message implementation varied significantly between studies with the majority of interventions delivered by multiple individuals. Teachers and other school faculty contributed to intervention delivery in sixteen studies (Pentz 1989; Murray 1994; Perry 1994; Tang 1997; Sussman 1998; Vartiainen 1998; Biglan 2000; Piper 2000; Schinke 2000; Hancock 2001; De Vries 2003; Schofield 2003; Perry 2003; Gordon 2008; Perry 2008; Hawkins 2009) and were trained by study investigators or paid research staff. The level of training varied between studies and within study clusters, for example in De Vries 2003, the largest study including six countries, training for teachers varied from two to forty-eight hours. Adult and youth volunteers contributed as trained volunteer leaders (Sussman 1998; D'Onofrio 2002), volunteers for Big Brother and Big Sister tutoring programmes (Hawkins 2009), peer narrators for prevention information (Gordon 2008) or other roles (Biglan 2000; Elder 2000; Hancock 2001). Peers were also elected by teachers or fellow class mates and were trained to act as role models and deliver influential programme messages for seven studies (Pentz 1989; Winkleby 1993; Perry 1994; Vartiainen 1998; Perry 2003; Schofield 2003; Perry 2008). Similarly, five studies recruited parents as channels to enhance and deliver programme information (Elder 2000; Schinke 2000; De Vries 2003; Schofield 2003; Gordon 2008). Research or project staff delivered the intervention directly to individuals only in four studies (Sussman 1998; Vartiainen 1998; Winkleby 2004; Gordon 2008) whilst specialised groups were used for six studies. These groups included cancer Council health educators, (Hancock 2001) health and human services workers for community based, youth focused and family focused programmes, (Hawkins 2009) government level policies, (Klein 2009) paediatric primary care clinicians, (Stevens 2002) and law enforcement (Schinke 2000; Perry 2003).

 

Follow-up:

The duration of follow up at which smoking status was assessed differed between studies and in some cases was not clear. Outcomes were measured, for example, at the end of the intervention (Baxter 1997; Gordon 1997; De Vries 2003), one year later (Sussman 1998; Baxter 1997; Hancock 2001), approximately one and a half years later (Elder 2000; D'Onofrio 2002), three and a half years later (Schinke 2000), and in the case of one study, fifteen years after the intervention (Vartiainen 1998).

 

Outcome collection:

Smoking behaviour was assessed in all studies by self-report, though two studies used face-to-face interviews for data collection purposes. A number of different intermediate outcomes were measured, including knowledge about the effects of smoking, attitudes toward smoking and intentions to smoke in the future. Chemical validation occurred in eight studies by exhaled carbon monoxide (Pentz 1989; Winkleby 1993; Murray 1994; Sussman 1998; Biglan 2000; Elder 2000; Piper 2000; Winkleby 2004) in addition to plasma thiocyanate levels for one study (Winkleby 1993). A random number of students in half of the school classes in the Perry 1994 study were assessed for saliva thiocyanate levels, whilst in the Schinke 2000 trial only a small proportion were analysed. Researchers in the Piper 2000 study collected exhaled carbon monoxide samples for bogus pipeline measures only.

Outcome collection occurred through different methods which could also differ at various time points throughout the study and in some trials methods, were not clear. These include research staff and trained data collectors in nine studies, (Pentz 1989; St Pierre 1992; Perry 1994; Sussman 1998; Vartiainen 1998; Piper 2000; Schofield 2003; Winkleby 2004; Perry 2008) school teachers and/or other faculty in eleven (Murray 1994; Baxter 1997; Gordon 1997; Tang 1997; Biglan 2000; Hancock 2001; De Vries 2003; Perry 2003; Schofield 2003; Gordon 2008; Hawkins 2009), via telephone calls in four studies (Biglan 2000; D'Onofrio 2002; Winkleby 2004; Klein 2009), postal questionnaires in six (Pentz 1989; Tang 1997; Vartiainen 1998; Biglan 2000; D'Onofrio 2002; Stevens 2002), and face-to-face in two (Winkleby 1993; Elder 2000). One study (Biglan 2000) sent $10 in an envelope with the questionnaire as an incentive for parents to complete and return the survey.

 

Risk of bias in included studies

Key methodological features of the twenty five included studies are summarised in the table of characteristics of included studies (Figure 2).

 FigureFigure 2. Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

 

Sequence generation:

Methods for choosing intervention and control areas varied across studies and in some cases the details provided were unclear. Some studies chose areas specifically to target particular groups of young people such as those with a high risk of substance abuse (Sussman 1998). In some studies the allocation of areas, communities or schools within particular geographical regions to either intervention or control was random (Schinke 2000), whilst for other studies allocation was random after communities or areas had been matched on a number of different factors. The investigators described a random component for sequence generation in eight studies (Gordon 1997; Biglan 2000; Hancock 2001; Schinke 2000; D'Onofrio 2002; Winkleby 2004; Gordon 2008; Hawkins 2009) which includes coin tossing or the use of computer generated random number tables. Ten studies had inadequate sequence generation (Pentz 1989; St Pierre 1992; Winkleby 1993; Perry 1994; Baxter 1997; Tang 1997; Vartiainen 1998; Piper 2000; De Vries 2003; Klein 2009), and the remaining seven studies were unclear.

 

Allocation concealment:

Allocation concealment was inadequate in twelve studies, i.e. the assignment of participants was not conclealed from investigators (Pentz 1989; St Pierre 1992; Winkleby 1993; Murray 1994; Perry 1994; Baxter 1997; Tang 1997; Vartiainen 1998; Piper 2000; De Vries 2003; Klein 2009), and unclear in the remaining thirteen.

 

Blinding for participants and outcome assessors:

All studies were inadequate in terms of blinding for participants due to the nature of a community-delivered intervention. No authors mentioned any attempts to conceal subject allocation from outcome assessors.

 

Incomplete outcome data:

Complete reporting of outcome data occurred in five studies (Vartiainen 1998; De Vries 2003; Perry 2003; Perry 2008; Hawkins 2009), which accounted for attrition in the sample population and described methods of handling missing variables in data sets, such as via random imputation or removal of data sets missing 90% of the responses etc. Five other studies failed to address incomplete outcome data. Baxter 1997 had significant amounts of data missing from one of the intervention schools and three classes in the control school; Hancock 2001 failed to mention characteristics of participants unable to be followed up and mentioned the collection of weekly and ever smoking data outcomes, however the data was not presented as it was deemed 'very similar' to the results for monthly smoking. The Klein 2009 study was unable to collect data at some time points due to gaps in funding, whereas the Piper 2000 study were unable to schedule in-school surveys for two intensive and one control school despite attempts. Both the Hancock 2001 and St Pierre 1992 studies mentioned outcome variables as being collected, which were not reported in the publications. The remaining fourteen studies had unclear reporting of incomplete outcome data.

 

Selective reporting:

Selective reporting was unclear in nine studies (Murray 1994; Baxter 1997; Gordon 1997; Sussman 1998; Vartiainen 1998; Schinke 2000; Perry 2003; Schofield 2003; Winkleby 2004) and was a high risk of bias for the remaining fifteen. Examples of selective reporting include outcomes reported incompletely with missing n-values for separate intervention and control groups or as a visual representation only which can not be meta-analysed or studies failing to include results for a key outcome which would be expected to be reported for such a study.

 

Imbalance of outcome measures at baseline:

Three studies (Winkleby 1993; Baxter 1997; Schofield 2003) failed to address imbalances in outcome measures at baseline, five studies were unclear (Tang 1997; Gordon 1997; Hancock 2001; Perry 2003; Winkleby 2004), whilst the remaining seventeen studies accounted for any imbalances in outcome measures at baseline through statistical measures.

 

Comparability of intervention and control characteristics at baseline:

Only one study failed to address comparability of intervention and control group characteristics at baseline. In Pentz 1989 the authors mentioned a possibility of non-equivalence of study groups, since the majority of schools were assigned to programme and control conditions based on administrator flexibility. No adjustments were made in the analysis to account for these imbalances. Thirteen studies adequately addressed imbalances in intervention and control characteristics at baseline through statistical adjustments or did not have any significant imbalances (St Pierre 1992; Winkleby 1993; Murray 1994; Perry 1994; Vartiainen 1998; Piper 2000; Schinke 2000; Hancock 2001; D'Onofrio 2002; Stevens 2002; Perry 2008; Hawkins 2009; Klein 2009). The remaining 11 studies had unclear comparability between study characteristics at baseline.

 

Protection against contamination:

Seven studies had potential sources of contamination: A state-wide tobacco education programme was initiated in 1990, which may have affected the control group results in the D'Onofrio 2002 study. The control group in the Netherlands for the De Vries 2003 study also underwent a national smoking prevention programme simultaneously with the evaluation for this programme. The Elder 2000 study had schools containing both intervention and control groups within them, whilst authors in the Gordon 1997 study mentioned contamination as a difficulty in their discussion. St Pierre 1992 provided the intervention to boys and girls clubs, a setting in which authors believe a natural 'booster programme' effect may have occurred for both prevention groups, thus making the two treatment groups similar. In addition, 87% of the 'SMART only' and 87% of the 'controls' reported learning about alcohol and other drugs from an intervention programme at school. For the Tang 1997 study, authors mention a possibility that little difference existed between the extent of exposure for intervention and control conditions. Furthermore, a comprehensive programme aimed at reducing the sale of cigarettes to minors was implemented in the control in Northern Sydney during the closing stages of the evaluation. Finally the Winkleby 1993 study had possible contamination due to one control city banning public smoking in 1990 which subsequently produced a large decline in smoking. One-third of survey respondents for this study did not live in the treatment cities during the entire intervention period. Although authors adjusted for this in their analysis the results did not change. Six studies were adequately protected against contamination (Perry 1994; Vartiainen 1998; Biglan 2000; Hancock 2001; Perry 2003; Winkleby 2004), whilst the remaining 12 studies had unclear protection against contamination.

 

Selective recruitment of participants:

Selective recruitment of participants were unclear in 18 studies and a high risk of bias in the remaining seven (Pentz 1989; St Pierre 1992; Piper 2000; De Vries 2003; Winkleby 2004; Hawkins 2009; Klein 2009). Possible selective recruitment occurred through subjects volunteering to take part in the evaluation, subjects selected by school teachers or by study staff.

 

Other risks of bias:

Two studies were identified as having other possible threats to validity. In Piper 2000, authors found significant differences between the different proposed methods of analysis used for the same data. As such they presented the results with 'the least amount of bias in the estimates of the standard errors due to the design effect'. The other study, D'Onofrio 2002, had a significant gap between study completion and publication of results (12 years). In addition authors state that different interventions were delivered to each intervention group and the full intervention as it was intended was not delivered, with an average delivery of 67%. The Baxter 1997 and Elder 2000 studies provided insufficient information to permit judgement of 'yes or no', while the remaining 21 studies had no other sources of bias identified.

 

Effects of interventions

See:  Summary of findings for the main comparison Community interventions for preventing smoking in young people

Intervention effectiveness was assessed in all 25 included studies through smoking prevalence, in addition to a mixture of secondary outcomes including behaviours, attitudes, perceptions and knowledge. The data was analysed as per the pre-defined methods described in 'Subgroup analysis and investigation of heterogeneity'. For a summary of intervention effectiveness for each of these outcomes see  Table 1.

 

Overall summary of smoking behaviour:

Overall ten interventions presented in the 25 studies demonstrated intervention effectiveness in influencing smoking behaviour including prevention, at primary follow up. One programme provided statistically and clinically significant short-term benefits (<12 months) (Winkleby 2004) and nine provided longer-lasting effectiveness (Pentz 1989; St Pierre 1992 (only in post hoc testing); Perry 1994; Vartiainen 1998 (up until eight-year follow up); Biglan 2000 (for 12- and 48-month follow ups only); De Vries 2003 (at 30 months only); Perry 2003 (for boys only in the D.A.R.E. Plus intervention; and when combining both D.A.R.E. and D.A.R.E. Plus groups together and comparing to control for the meta-analysis); Perry 2008; Hawkins 2009). Two interventions favoured the control group (Piper 2000; Hancock 2001), whilst the remaining 13 studies demonstrated no significant benefit.

Narrative synthesis has been used to report primary outcomes, secondary outcomes and process measures for all studies ( Table 2). A combination of 16 studies were able to be included in the meta-analyses, with eight studies being the largest number of studies available for one outcome. However these results should be interpreted with caution as outcomes are only reported for studies in which data were available for meta-analyses. Of the studies categorised as showing evidence of clinically and statistically significant benefit, only two (Vartiainen 1998, Perry 2008) reported outcomes that could be included in the meta-analysis. Smoking was assessed as daily ( Analysis 1.1), weekly ( Analysis 1.2), monthly ( Analysis 1.3), ever smoked ( Analysis 1.4) and smokeless tobacco use ( Analysis 1.5). Sub-group analyses were conducted based on intervention duration < 12 months and > 13 months. There were no statistically or clinically significant results for weekly, monthly or smokeless tobacco use. For daily smoking and 'ever smoked' the point estimates were consistent with a clinical benefit but the number of studies were small and the confidence intervals wide (daily smoking  Analysis 1.1, two studies, OR 0.89 (95% CI 0.69 to 1.15)), (ever smoked  Analysis 1.4, three studies, OR 0.82 (95% CI 0.39 to 1.74)).

An alternative subgroup analysis (Analysis 2) using length of follow up rather than duration of intervention, did not provide any evidence that this affected outcomes or explained heterogeneity. Studies could contribute to both short and long follow up groups, but there was not enough data to detect whether intervention effect might increase or decline over time.

The Pentz 1989 study reported reductions in the intervention community versus the control community, who received the media component only, whilst in post hoc analyses of the St Pierre 1992 study, both intervention groups reported significant reductions in cigarette use over that of the control group (p<0.05). Both Perry 1994 and Vartiainen 1998 programmes were initially designed as large-scale, cardiovascular disease prevention programmes aimed at entire populations, and included a school-based component specifically targeting young people. Although smoking outcomes in the Vartiainen 1998 study were not significant at 15-year follow up, significant effects in favour of the intervention were seen for daily and weekly smoking up until 8-year follow up (p=0.035 and p=0.022 respectively), and for monthly smoking up until 4-year follow up (p=0.004). The Biglan 2000 study reported reductions in the community intervention group compared with a school based programme only. Perry 2003 compared two interventions to a control population with a statistically significant difference observed amongst boys in the 'D.A.R.E. Plus' intervention and a clinically significant difference for the combined gender population for the same intervention. For the De Vries 2003 study the results were diverse due to the large scale of the project (interventions delivered across six countries). Reductions in smoking onset were observed in two of the six countries as well as increased smoking observed in two of the six countries, being Denmark and the UK showing counterproductive trends at 12 months. At 24 months no overall significant effects were seen despite two countries significantly favouring the intervention. Whilst at 30 months an overall significant effect in favour of the interventions was seen (p=0.03) with two countries showing statistically and clinically significant benefits. De Vries 2003 was unable to be included in the meta-analysis as authors excluded current smokers at baseline from all analyses, only following up those initiating smoking after baseline samples were collected. As such this study could not be compared to the other community trials included in this review which assessed the programme's influence on smoking behaviour in addition to prevention, rather than prevention alone. Due to the large scale of the evaluation, a separate table summarising each of the outcomes at each follow up period has been included ( Table 3). In the Perry 2008 by two-year follow up, overall tobacco use increased by 68% in the control group whilst a decrease of 17% was found in the intervention group. Significant between group differences in favour of the intervention were found for trajectories of cigarette smoking (p<0.05), bidi smoking (p<0.01) and any tobacco use (p<0.04) (Perry 2008). In both Winkleby 2004 and Hawkins 2009, community programme efforts were combined with a school based component to decrease smoking prevalence in the intervention group, whilst an increase was observed in the control population. In addition the Hawkins 2009 study demonstrated a significant reduction in smokeless tobacco use for the intervention population compared to the control.

Although Elder 2000 showed no significant effects overall for smoking prevention, the time x treatment analysis of the 'susceptible cohort' showed a significant result in favour of the intervention at 12- and 24 months post study commencement. Similarly, the Gordon 2008 study produced no significant effects for the population as a whole or for 'cohort 1' separately, however 'cohort 2' showed a significant effect in favour of the intervention at 12-months follow up. Authors report data for the four group comparison study in the Murray 1994 papers as showing no significant effects. However for the purposes of this analysis the three intervention groups have been combined and compared to the control group, which subsequently produced a marginally significant finding in favour of the control (p=0.05), although the confidence intervals do touch the line of no effect (95% CI 1.00 to 1.51, odds ratio 1.23).

 

Overall summary of secondary outcomes:

Secondary outcomes including behaviours, (intentions to smoke, rules on smoking) attitudes, (advantages, disadvantages, peer attitudes, overall attitudes, okay for young people to smoke) perceptions (peer smoking, norms) and knowledge (total, first use harmful/mild okay) had mixed results. For a summary of the intervention effectiveness at each reported study follow-up period see  Table 1. At final follow up a total of eight studies assessed smoking behaviours of which five favoured the intervention: Gordon 1997; Biglan 2000; Perry 2003; for combined D.A.R.E and D.A.R.E Plus groups (Gordon 2008); for time x treatment analysis only (Perry 2008); one study favoured the intervention for two out of six countries (De Vries 2003), and two had no significant benefit (D'Onofrio 2002; Klein 2009). Nine studies assessed attitudes, out of which five favoured the intervention (Gordon 1997; Biglan 2000; Elder 2000 (for time x treatment analysis only on tobacco-anticipated outcomes); De Vries 2003 (for 2/6 countries only); Perry 2008), three showed no statistical difference between groups, whilst adjusted data in the Tang 1997 study for the outcome 'okay for young people to smoke' favoured the control, despite the overall meta-analysis for this outcome favouring the intervention (p=0.02). Perceptions were assessed in six studies of which two favoured the intervention, (Biglan 2000; Piper 2000 (for Intensive HFL only, the Age appropriate HFL produced no significant benefit)), one favoured the control (Perry 2008) and three produced no significant differences between groups (Tang 1997; D'Onofrio 2002; Klein 2009). Finally, knowledge scores favoured the intervention in three (St Pierre 1992; Schofield 2003; Perry 2008) of the six studies which assessed this outcome, whilst the remaining three studies (Gordon 1997; Tang 1997; D'Onofrio 2002) showed no significant effect.

A combination of five studies were able to be included in the meta-analyses, with three studies being the largest number available to assess one outcome. Behaviours were assessed as rules on smoking at home ( Analysis 3.1) which showed a statistically and clinically significant effect favouring the intervention (OR 1.10 (95% CI 1.02 to 1.18), p=0.009), and intentions to smoke ( Analysis 3.2), which also had a statistically non-significant but clinically significant effect favouring the intervention. Perceptions of peer smoking were also pooled from two studies which did not show a significant result ( Analysis 4.1).

The De Vries 2003 study which was the largest containing six countries could not be included in the meta-analyses due to the exclusion of baseline smokers from further follow up, as such a comparison to the other studies included in this review cannot be made. At 12-months follow up the intervention groups from Spain and the UK reported significant results favouring the control for 'intentions to smoke in the next year', whilst the remaining four countries showed no significant effect. However at 24-months follow up a significant effect in favour of the control was only seen in The Netherlands, while a beneficial effect was seen in Portugal. This changed again at 30-months follow up with a beneficial effect in Portugal as well as the UK, whilst no significant differences were seen in the remaining four countries. The experimental group was significantly less convinced of the pros of smoking (or cons of not-smoking) compared to the control group in one out of six countries at 12 months, three out of six counties at 24 months (resulting in an overall effect in favour of the intervention p<0.05) and two out of six countries at 30 months (also see  Table 3).

 

Statistical analysis and cluster adjustments:

All studies allocated either entire countries, communities, schools or clubs to intervention or control groups. Seventeen studies accounted for the unit of allocation in their analyses, usually through hierarchical modelling or analysis of variance/covariance (Pentz 1989; Murray 1994; Perry 1994; Sussman 1998; Vartiainen 1998; Biglan 2000; Elder 2000; Piper 2000; Hancock 2001; D'Onofrio 2002; De Vries 2003; Perry 2003; Winkleby 2004; Gordon 2008; Perry 2008; Hawkins 2009; Klein 2009). Eight studies presented the results with the individual as the unit of analysis (St Pierre 1992; Winkleby 1993; Baxter 1997; Gordon 1997; Tang 1997; Schinke 2000; Stevens 2002; Schofield 2003). For these eight studies a manual adjustment for clustering was made using a design effect of 1.2 as described in the methods above under 'Unit of analysis issues'.

For the sub-group 'Length of follow up, thirteen months or more', the longest available follow up was used for all outcomes in the data and analysis sections, the longest of which was Vartiainen 1998 with a 15-year follow up reported. Some studies presented interim results which are not included in this meta-analysis, however these results are discussed in more detail within the text and are documented in  Table 1.

 

Sub-group analyses by length of follow up:

Seven studies supplied results for follow up at twelve months or less which were able to be included in the meta-analyses, and ten studies for follow up of thirteen months or more.

 
Smoking behaviour:

Smoking was assessed as daily ( Analysis 2.1), weekly ( Analysis 2.2), monthly ( Analysis 2.3), ever smoked ( Analysis 2.4) and smokeless tobacco use ( Analysis 2.5). For short-term follow up all outcomes demonstrated no significant effect. Significant heterogeneity (as assessed via multiple sources) was observed for the monthly and ever smoked outcomes with an I-squared statistics of 70% and 64% respectively. As such these results should be interpreted with caution. For long-term follown up (13 months or more) no statistically or clinically significant results were found for weekly or monthly tobacco use, however a statistically non-significant but clinically significant effect was found for daily and smokeless tobacco use favouring the intervention.

 
Secondary outcomes:

Secondary outcomes included youth attitudes ( Analysis 5.1;  Analysis 5.2;  Analysis 5.3;  Analysis 5.4;  Analysis 5.5;  Analysis 6.1;  Analysis 6.2), behaviours ( Analysis 5.6;  Analysis 5.7;  Analysis 6.3), knowledge ( Analysis 5.8;  Analysis 5.9) and perceptions ( Analysis 6.4), which are presented in the relevant analyses.

 

Cost effectiveness:

Costs of the interventions varied enormously amongst the few studies which provided details. One excluded study which reported the results for the UK Smokebusters programme in Wensleydale in 1992 stated that the project had cost approximately £6,000 to implement and evaluate (Davidson 1994). This was in comparison to a state wide initiative in the USA (implemented in 1985) which received a total of $2 million per year funded from higher taxes on tobacco products (Murray 1994). Through the prevention of adolescent smoking, Murray 1994 estimate the total monetary savings related to public health implications in the Kansas city area at $40 679 for each boy and $13 232 for each girl.

 

Process Measures

A variety of different process measures were recorded for the number of different activities participants engaged in (St Pierre 1992; D'Onofrio 2002; De Vries 2003; Schofield 2003), the percentage of students who took part in each activity (Sussman 1998; Stevens 2002; Schofield 2003; Winkleby 2004; Perry 2008; Hawkins 2009), saw media advertisements (Murray 1994), details about the actual implementation of the programme (Pentz 1989; Sussman 1998; Stevens 2002; De Vries 2003; Schofield 2003; Perry 2008; Hawkins 2009) and process measures recorded through teacher feedback questionnaires (Tang 1997). One study showing no impact on smoking prevalence also reported no significant difference in awareness of anti-smoking campaigns or association between awareness and smoking status (Hancock 2001).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

Twenty-five studies evaluating the effectiveness of community interventions met the inclusion criteria for this review, representing a diverse set of interventions. Five focused on reducing specific health risk factors for cancer (Hancock 2001) or cardiovascular disease (Winkleby 1993; Perry 1994; Baxter 1997; Vartiainen 1998) with influencing smoking behaviour as a secondary component of the programme, seven studies combined tobacco prevention with either reduction or cessation initiatives (Pentz 1989; Murray 1994; D'Onofrio 2002; De Vries 2003; Perry 2003; Winkleby 2004; Hawkins 2009) whilst the remaining thirteen focused exclusively on influencing smoking behaviour including prevention initiatives.

Of these 25 studies, ten were associated with a reduction in the uptake of smoking amongst young people (Pentz 1989; St Pierre 1992; Perry 1994; Vartiainen 1998; Biglan 2000; De Vries 2003; Perry 2003; Winkleby 2004; Perry 2008; Hawkins 2009). Common features to these successful programmes include nine of the ten incorporating school based multi-component interventions with intervention delivery by school teachers and other faculty members, six had parental involvement in the intervention programme, eight had intervention durations longer than 12 months and nine of the ten interventions were based on the social influences or social learning theory. The exception was Hawkins 2009 which used the social development model (Catalano 1996; Fleming 2008). However the development of programmes to influence smoking behaviour with theoretical concepts exclusively based on the social influences approach, has been criticised in the literature (Bauman 1996; De Vries 2003), with suggestions that indirect peer pressure may be just as effective to prevent peer smoking. Five of the seven studies combining tobacco prevention with either reduction or cessation initiatives were successful in influencing the smoking behaviour of young people (Pentz 1989; De Vries 2003; Perry 2003; Winkleby 2004; Hawkins 2009). Three of the five studies which included community leader participation with active involvement in both the development and ongoing support of the community programmes were also effective in reducing youth smoking (Perry 1994; Perry 2003; Hawkins 2009), however the remaining two studies, Piper 2000 (for the Age Appropriate intervention) and Hancock 2001 showed significant benefits in favour of the control. Five of the nine studies including mass-media as additional programme components favoured the intervention (Pentz 1989; Perry 1994; Biglan 2000; De Vries 2003; Perry 2008).

Eight of the 13 unsuccessful programmes had intervention durations of 12 months or less with a mean of 2.5 years for the remaining seven studies. Community leader involvement in both the development and ongoing support for the programmes occurred in one of the 13 unsuccessful studies, with Hancock 2001 being the exception. However the primary focus of the Hancock 2001 study was cancer prevention, as such the community leader involvement was not primarily focused on influencing youth smoking behaviour. Seven of the unsuccessful programmes also used the social influences model, three used community action/organisation theory (Winkleby 1993; Hancock 2001; Schofield 2003) and five used other theories, for example office system's approach (Stevens 2002), modifiable risk factors to influence youth smoking (Baxter 1997; Klein 2009), social acceptance (Gordon 2008) or an unclear theoretical basis (Gordon 1997). Four of the thirteen unsuccessful campaigns used mass media as a programme component, four had peer involvement to act as role models and deliver programme components, thirteen involved school based intervention components and ten included parent participation. A suggestion has been made that the most substantial increases in adolescent tobacco use occur later in high school and as such, parental communication has its impact not on the age of first experimentation but rather on later regular use (Stevens 2002). Therefore, investigations of young cohorts which use parental influences for the prevention intervention, should continue follow up into high school for a more accurate example of parental influences on smoking prevention. Five of the successful studies used peers as role models, in comparison to four of the thirteen unsuccessful studies. According to current literature the perceived prevalence of smoking in the community influences youth smoking behaviours, which was confirmed in the Klein 2009 study. In this study, authors report that the influence of friends' smoking status rendered a more powerful influence on smoking behaviour that the programme policy alone. Youth with close friends who smoked were more likely to smoke than youth with no close friends who smoke, which was consistent with the De Vries 2003 study.

The lack of community leader involvement, mass media intervention components and peer influences to support the community interventions, such as those in the successful campaigns, likely attributes to the eventual failure in influencing youth smoking behaviour, in these unsuccessful programmes.

One of the two studies which produced a negative effect for smoking prevalence, (Hancock 2001), had a focus of cancer prevention; with influencing youth and adult smoking behaviour as secondary components. Methodological flaws such as small sample size, lack of biological validation for abstinence, nonsensical responses in surveys and lower consent rates in the second cross-sectional survey are discussed, however this does not necessarily provide a reason for the failing of the intervention programme. The authors do state a concern regarding process measures through school principal reports of anti-smoking activities in the past two years, which may provide some reasoning for the observed effect. No significant differences were found between treatment and control schools for reported activities, which suggests that many similar activities occurred in control towns and schools as happened in the intervention towns and schools. Piper 2000 reported different effects on smoking prevalence between two different versions of an intervention, compared with a control group receiving standard health education. At three-year follow up monthly smoking in the Age Appropriate intervention was 36% (p<0.01) compared to 30% in the control and 28% in the Intensive intervention. Authors suggest a number of explanations for these findings including: insufficient time available to effect cultural change, saturation of the prevention message by 8th grade (coined the 'fatigue factor'), implementation difficulties (only in the Age Appropriate arm), insufficient time and resources for the community level interventions, lack of intervention tailoring for specific sub-populations, multiple intervention messages which have different social meanings to different sub-groups and inadequate control as numerous health promotion and prevention programmes were run throughout the elementary and middle-school years.

Some dichotomy is emerging in the uptake of smoking between genders. As mentioned in the background, current reports indicate that smoking behaviour among adolescent girls is increasing over that of boys (Mackay 2006; Warren 2009). The Perry 2003 study did show a significant difference amongst boys in the D.A.R.E. Plus group compared to the controls for tobacco use, which was not present in the female population. This was also seen in the Schofield 2003 study. Authors state their findings strongly support the more widespread gender trend in which girls are nearly twice as likely as boys to be smokers in the early adolescent period. As a result consideration should be given to gender-specific prevention and cessation programmes during early adolescence in the future. It is also worth noting that there is an increasing trend in the use of bidi smoking, especially in India as per the Perry 2008 study. There is a misinformed notion amongst youth that bidi smoking (also spelled beedis or beedies) is less harmful than regular cigarettes as they look herbal due to the leaf wrapping and they come in a variety of flavours such as vanilla, chocolate, strawberry, mango, cherry etc. However, they do not contain filters like cigarettes and contain less tobacco but more nicotine (Rahman 2000). One study found that one bidi produced more than three times the amount of carbon monoxide and five times the amount of tar than one cigarette (Watson 2003). Furthermore, they contain chemicals such as hydrogen cyanide, ammonia and phenol in greater quantities than normal cigarettes and to keep bidis lit, more frequent and deeper puffs are required in comparison to cigarettes (Gupta 2008).

Where possible we pooled pre-specified outcomes in meta-analyses, however these results should be considered with caution as some studies did not report in a way that allowed data to be included. Furthermore, we used the outcome at the final follow-up periods in these meta-analyses, with the exception of the sub-group 'Length of follow up 12 months or less'. Many studies provided data at multiple time periods. As a result some of the studies are not represented within these analyses and the outcomes may be misleading. Most of the studies which reported significant benefits could not be included in the meta-analysis. For this reason we recommend consideration be given to data presented in  Table 1 and  Table 2 when interpreting each outcome.

When combining studies in the meta-analysis to measure smoking prevalence rates, significant heterogeneity was identified for a number of outcomes as determined via multiple sources including I-squared statistic, visual inspection of the data and characteristics of studies. Where appropriate, the analysis methods of outcomes were changed from the fixed effect to the random effect model as outlined in the methods. It has been recognised that community-wide programmes are especially difficult to evaluate (CART 1996a) and that many community interventions have failed to meet the criteria for rigorous scientific evaluation (CART 1996b). For example, there are particular difficulties in establishing adequate control groups (CART 1996a). Communities (or large groups) have to be assigned to either intervention or control groups rather than individuals, which means that the analysis of outcomes should be at the level of the community rather than the individual. The unit of analysis however is often presented at the individual level due to the increased power supplied to the study, which in turn gives a greater chance of finding positive programme effects. Ignoring the correct unit of analysis may lead to spurious positive findings (Altman 1997). For example one study (Murray 1992; Murray 1994) reported that if clustering had been ignored and the results had been based on the individual as the unit of analysis (without adjustment) then there would have been a spurious significant difference between the two groups, with the 2.4% net decline in smoking behaviour in the intervention state being reported as significant. One of the first community trials to employ GEE to address clustering problems was D'Onofrio 2002. They have published another paper contrasting GEE with more common analytic methods using the data from Murray 1996. Clustering was addressed in this meta-analysis through reducing the size of the trial to the effective sample size (Rao 1992) using the original sample size from each study, divided by a design effect of 1.2 which is consistent with other smoking cessation community intervention trials (Gail 1992).

Using youth within schools as sampling units may limit the generalisability of the findings. Only six studies did not use schools as the sampling unit (St Pierre 1992; Winkleby 1993; Elder 2000; D'Onofrio 2002; Stevens 2002; Klein 2009). In one study all age-eligible persons within randomly selected households were sampled, therefore, increasing the likelihood of including young people at high risk for smoking who may be missed when students within schools are sampled. In their sample of 19 to 24 year-olds approximately ten per cent were high school drop-outs and their levels of smoking were significantly higher than those students completing high school (50% versus 20%) (Winkleby 1993). As the individuals sampled in most studies were predominantly students within schools, it is unclear how the results may generalise to young people outside of the school system. As mentioned in the results, nine studies did not adjust for clustering effects within the analysis, as such a manual adjustment for clustering was made using a published design effect (Gail 1992).

Despite methodological problems common to several of the studies which met the inclusion criteria for this review, they represent the most rigorous set of studies available evaluating the effectiveness of community interventions in influencing the smoking behaviour of young people. It is important to recognise that community programmes are influenced by local factors and are likely to be difficult to replicate exactly in other settings. However, the principles and methods upon which an effective intervention was based could be useful for programme implementation in similar settings.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

 

Implications for practice

Overall, there is some limited support for the effectiveness of community interventions in influencing smoking behaviour, including the prevention of smoking in young people. The following programme characteristics could be considered by individuals involved in planning future community programmes:

  • build upon elements of existing programmes (particularly those including multi-component school based interventions, parental involvement, intervention duration longer than 12 months and based on the social influences or social learning theory model), that have been shown to be effective rather than repeating methods that have achieved limited success;
  • programmes need to be flexible to the variability between communities so that the different components of a given programme can be modified to achieve acceptability;
  • developmental work with representative samples of those individuals to be targeted should be carried out so that appropriate messages and activities can be implemented;
  • programme messages and activities should be guided by a combination of theoretical constructs about how behaviours are acquired and maintained;
  • community activities must reach the intended audience if they are to stand any chance of success of influencing the behaviour of that audience;
  • consider the use of community leader involvement in the planning, development and ongoing implementation of community programmes, mass media as a source of message delivery, the use of peers as role models and specific programme components for boys and girls separately.

 
Implications for research

  • The evaluation of community-wide campaigns to influence smoking behaviour is methodologically challenging, yet rigorous evaluation is required in order to demonstrate effectiveness. Careful planning of the evaluation is required, in terms of: analysis at the correct level, for example if communities are the unit of allocation then they should also be the unit of analysis or alternatively the unit of allocation should be accounted for in the analysis.
  • Measurement of appropriate outcomes: different levels of measurement should be planned, including behavioural, intermediate (or mediating) and process. The adequacy of implementation of each component of the intervention should also be recorded.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

Firstly, we would like to thank Lindsay Stead and Monaz Mehta for carrying out an extensive set of searches, obtaining full text for included studies, providing recommendations, ongoing support and most importantly their patience during the update.

We would also like to thank Keith Smolkowski, Judith Gordon, Steven Schinke, Joel Moskowitz and Cheryl Perry for supplying raw data and Tena St Pierre for responding to the requests for raw data.

Thank you to Veronica Pitt, Miranda Compton and all the staff at the Monash Cochrane Centre in Melbourne for their guidance and advice, and peer reviewers for their useful comments.

Laura Arblaster was an author on the first version of this review and Amanda Sowden and Lindsay Stead updated the review from issue 1, 2003.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms
Download statistical data

 
Comparison 1. Reported tobacco use

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Smoking - Daily2Odds Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 Intervention duration 13 months or more
21304Odds Ratio (M-H, Fixed, 95% CI)0.89 [0.69, 1.15]

 2 Smoking - weekly611363Odds Ratio (M-H, Fixed, 95% CI)1.00 [0.90, 1.11]

    2.1 Intervention duration 12 months or less
21323Odds Ratio (M-H, Fixed, 95% CI)0.90 [0.67, 1.21]

    2.2 Intervention duration 13 months or more
410040Odds Ratio (M-H, Fixed, 95% CI)1.02 [0.91, 1.14]

 3 Smoking - monthly818677Odds Ratio (M-H, Random, 95% CI)0.98 [0.84, 1.14]

    3.1 Intervention duration 12 months or less
26326Odds Ratio (M-H, Random, 95% CI)1.01 [0.87, 1.16]

    3.2 Intervention duration 13 months or more
612351Odds Ratio (M-H, Random, 95% CI)0.96 [0.77, 1.20]

 4 Smoking - ever smoked3Odds Ratio (Random, 95% CI)Subtotals only

    4.1 Intervention duration 12 months or less
3Odds Ratio (Random, 95% CI)0.82 [0.39, 1.74]

 5 Smokeless tobacco use37667Odds Ratio (M-H, Random, 95% CI)0.78 [0.50, 1.22]

    5.1 Intervention duration 12 months or less
23485Odds Ratio (M-H, Random, 95% CI)0.98 [0.76, 1.26]

    5.2 Intervention duration 13 months or more
14182Odds Ratio (M-H, Random, 95% CI)0.50 [0.35, 0.72]

 
Comparison 2. Reported tobacco Use, Subgroup by length of follow-up

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Smoking - daily2Odds Ratio (M-H, Fixed, 95% CI)Subtotals only

   1.1 Length of follow-up 12-months or less
00Odds Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Length of follow-up 13-months or more
21304Odds Ratio (M-H, Fixed, 95% CI)0.89 [0.69, 1.15]

 2 Smoking - weekly6Odds Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Length of follow-up 12-months or less
21432Odds Ratio (M-H, Fixed, 95% CI)1.07 [0.76, 1.51]

    2.2 Length of follow-up 13-months or more
510707Odds Ratio (M-H, Fixed, 95% CI)1.00 [0.90, 1.12]

 3 Smoking - monthly8Odds Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 Length of follow-up 12-months or less
37128Odds Ratio (M-H, Random, 95% CI)1.00 [0.71, 1.43]

    3.2 Length of follow-up 13-months or more
712833Odds Ratio (M-H, Random, 95% CI)0.96 [0.79, 1.17]

 4 Smoking - ever smoked3 (Random, 95% CI)0.82 [0.39, 1.74]

    4.1 Length of follow-up 12-months or less
2 (Random, 95% CI)1.03 [0.60, 1.80]

    4.2 Length of follow-up 13-months or more
1 (Random, 95% CI)0.18 [0.03, 1.00]

 5 Smokeless tobacco use3Odds Ratio (M-H, Random, 95% CI)Subtotals only

    5.1 Length of follow-up 12-months or less
23597Odds Ratio (M-H, Random, 95% CI)0.98 [0.73, 1.33]

    5.2 Length of follow-up 13-months or more
24849Odds Ratio (M-H, Random, 95% CI)0.67 [0.37, 1.22]

 
Comparison 3. Reported behaviours

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Behaviours - rules on smoking2 (Fixed, 95% CI)Subtotals only

    1.1 Intervention duration 13 months or more
2 (Fixed, 95% CI)1.10 [1.02, 1.18]

 2 Behaviours - intentions to smoke3 (Random, 95% CI)0.52 [0.21, 1.29]

 
Comparison 4. Reported perceptions

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Perceptions - peer smoking2 (Random, 95% CI)0.98 [0.78, 1.24]

    1.1 Intervention duration 13 months or more
2 (Random, 95% CI)0.98 [0.78, 1.24]

 
Comparison 5. Length of follow-up 12-months or less

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Attitudes - advantages/positives29006Mean Difference (IV, Random, 95% CI)-0.16 [-0.41, 0.09]

 2 Attitudes - toward smoking (total)1637Mean Difference (IV, Fixed, 95% CI)-0.05 [-0.21, 0.11]

 3 Attitudes - disadvantages/negatives18369Mean Difference (IV, Fixed, 95% CI)-0.46 [-1.56, 0.64]

 4 Attitudes - perceived peer attitudes1637Mean Difference (IV, Fixed, 95% CI)0.06 [-0.17, 0.29]

 5 Attitudes - okay for young people to smoke2Odds Ratio (Fixed, 95% CI)1.05 [1.01, 1.09]

 6 Behaviours - intentions to smoke25117Odds Ratio (M-H, Random, 95% CI)0.64 [0.28, 1.49]

 7 Behaviours - rules on smoking213246Mean Difference (IV, Random, 95% CI)0.24 [-0.24, 0.72]

 8 Knowledge - total11543Odds Ratio (M-H, Fixed, 95% CI)1.18 [0.96, 1.45]

 9 Knowledge - first use harmful/mild okay2Odds Ratio (Fixed, 95% CI)1.20 [0.94, 1.53]

 
Comparison 6. Length of follow-up 13-months or more

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Attitudes - toward smoking (total)1538Mean Difference (IV, Fixed, 95% CI)0.14 [-0.01, 0.29]

 2 Attitudes - perceived peer attitudes1532Mean Difference (IV, Fixed, 95% CI)0.13 [-0.12, 0.38]

 3 Behaviours - rules on smoking14233Odds Ratio (M-H, Fixed, 95% CI)0.82 [0.71, 0.95]

 4 Perception - peer smoking13277Odds Ratio (M-H, Fixed, 95% CI)0.89 [0.76, 1.05]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms
 

Appendix 1. Databases searched for previous updates of the review

Cancerlit (Dialog)1975 - 1998/9, NTIS (Dialog)1964 -1998/9, Diogenes (Dialog)1976 -1998/9, Business and Industry Index (Dialog)1984 -1998/9, Criminal Justice Periodical Index (Dialog) 1975 -1998/9, Management & Marketing Abstracts (Datastar) 1975 -1998/9, SIGLE (Blaiseline)1980 - 1998/9, Directory of Published Proceedings (Datastar) 1990 - 1998/9, Dissertation Abstracts (Dialog)1861 - 1998/9, Harvard Business Review (Dialog)1971 - 1998/9, DH-Data (Datastar and WinSPIRS)1983 - 1998/9 Healthstar (OVID)1975 - December 2001, CAB Health (Datastar)1973 -1998/9 (Winspirs) 1998 - September 2002, ABI/INFORM (Datastar)1971 -1998/9 (Proquest) 1998 - September 2002.

 

Appendix 2. ECONLIT search strategy

1     smoking.mp. [mp=heading words, abstract, title, country as subject]
2     (smoking or tobacco or cigarette$).mp.
3     1 or 2
4     (young people or child or children or juveniles or girls or boys or teenagers or adolescent$ or adolescence or minor$).mp.
5     (nationwide or statewide or countrywide or citywide).mp.
6     (nation wide or state wide or country wide or city wide).mp.
7     outreach.mp.
8     (multicomponent or multifacet or multifaceted or multidisciplinary).mp.
9     (field based or fieldbased).mp.
10     (interdisciplinary or inter disciplinary).mp.
11     local.ti. or citizen$.mp.
12     (community or communities).mp.
13     8 or 6 or 11 or 7 or 10 or 9 or 12 or 5
14     4 and 3 and 13

 

Appendix 3. EMBASE & PsycINFO search strategy

1     smoking.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
2     (smoking or tobacco or cigarette$).mp.
3     1 or 2
4     (young people or child or children or juveniles or girls or boys or teenagers or adolescent$ or adolescence or minor$).mp.
5     (nationwide or statewide or countrywide or citywide).mp.
6     (nation wide or state wide or country wide or city wide).mp.
7     outreach.mp.
8     (multicomponent or multifacet or multifaceted or multidisciplinary).mp.
9     (field based or fieldbased).mp.
10     (interdisciplinary or inter disciplinary).mp.
11     local.ti. or citizen$.mp.
12     (community or communities).mp.
13     8 or 6 or 11 or 7 or 10 or 9 or 12 or 5
14     4 and 3 and 13

 

Appendix 4. CSA Databases search strategy

Sociological Abstracts, British Humanities Index, PAIS, ERIC, ASSIA

Query: ((TI=cigarette* or smoking or tobacco) or(KW=cigarette* or smoking or tobacco) or(AB=cigarette* or smoking or tobacco)) and ((KW=young
people or child or children or juveniles or girls or boys) or (TI=young people or child or children or juveniles or girls or boys) or (AB=young people or child or children or juveniles or girls or boys)) and ((KW=(nationwide or statewide or countrywide or citywide or nation wide or state wide or country wide or city wide or outreach or multicomponent or multifacet or multifaceted or multidisciplinary or field based or fieldbased or interdisciplinary or inter disciplinary or local or citizen* or community or communities)) or(TI=(nationwide or statewide or countrywide or citywide or nation wide or state wide or country wide or city wide or outreach or multicomponent or multifacet or multifaceted or multidisciplinary or field based or fieldbased or interdisciplinary or inter disciplinary or local or citizen* or community or communities)) or(AB=(nationwide or statewide or countrywide or citywide or nation wide or state wide or country wide or city wide or outreach or multicomponent or multifacet or multifaceted or multidisciplinary or field based or fieldbased or interdisciplinary or inter disciplinary or local or citizen* or community or communities)))

 

Appendix 5. CENTRAL search strategy

#1 (smoking or tobacco or cigarette*):ti,ab,kw and (child* or juvenile* or girls or boys or teen? or teenager? or adolescen*):ti,ab,kw and (communit* or nation* or state* or country* or city* or outreach or (multi NEXT (component or facet or faceted or disciplinary)) or interdisciplinary or (field next based)):ti,ab,kw  
#2 sr-tobacco
#3 (#1 AND NOT #2)

 

Feedback

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms
 

Comment from Toshi Furukawa, 3 May 2013

 

Summary

Comment: This review is very confusing.

1) Why do you include non-randomised studies when you already have 15 randomised ones? Moreover, you do not seem to separate the two kinds in the funnel plots?

2) The narrative summary/abstract is totally non-congruent with your own SoF.

 I agree with the conflict of interest statement below:

 I certify that I have no affiliations with or involvement in any organization or entity with a financial interest in the subject matter of my feedback.

 

 

Reply

Thank you for your comments.

1) Why do you include non-randomised studies when you already have 15 randomised ones? Moreover, you do not seem to separate the two kinds in the funnel plots?

Originally when the review was conceived it was believed that the inclusion of randomised and non-randomised controlled trials combined would offer the readers with the best summary of evidence as it is sometimes quite difficult to randomise community level studies. Controlled clinical trials still have the potential to offer useful information pertaining to tobacco outcomes and as such were included. To take these difficulties into account this pre-specified methodology was carried out through to review completion despite the identification of a large number of randomised controlled studies so as not to introduce biases with changing approaches whilst conducting a review. However, as we are now approached another update for this review we agree with the comment and as such will be pre-specifying the exclusion of controlled clinical trials without randomisation. The funnel plots were not used to separate the differences between randomised and non-randomised controlled trials as again this was not a pre-specified approach. Funnel plots were only used in an attempt to identify selective reporting of studies as a whole. There are many tests that can be added on post hoc that we and many others would perhaps find interesting once the initial analyses are complete, however this introduces issues around selective reporting, which the pre-specified protocol aims to eliminate.

2) The narrative summary/abstract is totally non-congruent with your own SoF.

This will be corrected in the update and a consumer representative will be utilised to ensure that all components of the review are consistent and clearly understood.

Kristin V Carson (Queen Elizabeth Hospital, Adelaide, Australia)

 

Contributors

Toshi Furukawa (Kyoto University School of Public Health); Kristin V Carson (Queen Elizabeth Hospital, Adelaide, Australia)

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

Last assessed as up-to-date: 18 February 2011.


DateEventDescription

30 May 2013Feedback has been incorporatedOne comment received and addressed by the author.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

Protocol first published: Issue 3, 1997
Review first published: Issue 1, 2000


DateEventDescription

29 April 2011New citation required but conclusions have not changedNew author team. No major change to conclusions but changes include updated and reformatted characteristics of included studies table; risk of bias assessment for all included studies; updated format for data and analyses; characteristics of interventions table and summary of findings table.

29 April 2011New search has been performedEight new included studies; 29 new 'excluded but relevant' studies; two previously included studies now excluded;

18 June 2008AmendedConverted to new review format

24 September 2002New citation required but conclusions have not changedUpdated for 2003 issue 1. Two studies changed from unpublished to published. Four new studies included. No major changes to conclusions.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

Kristin Carson updated the protocol, reviewed the literature, identified studies for inclusion, performed data extraction on all included studies, entered and analysed data and updated the text of the manuscript.

Malcolm Brinn and Nadina Labiszewski performed second author data extraction, analysed data and updated the text of the manuscript.

Adrian Esterman directed the data analysis and also reviewed the manuscript.

Anne Chang reviewed the manuscript.

Brian Smith reviewed the manuscript and supervised the completion of the review.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms

None known

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Index terms
 

Internal sources

  • Respiratory Medicine Unit, The Queen Elizabeth Hospital, Australia.

 

External sources

  • Australasian Cochrane Airways Group Network Scholarship, Australia.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要Résumé scientifique摘要
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Baxter 1997 {published data only}
  • Baxter AP, Milner PC, Hawkins S, Leaf M, Simpson C, Wilson KV, et al. The impact of heart health promotion on coronary heart disease lifestyle risk factors in schoolchildren: Lessons learnt from a community-based project. Public Health 1997;111:231-7.
Biglan 2000 {published and unpublished data}
  • Biglan A, Ary DV, Duncan TE, Black C, Smolkowski K. A randomized control trial of a community intervention to prevent adolescent tobacco use (Draft report 1998). Oregon: Oregon Research Institute.
  • Biglan A, Ary DV, Smolkowski K, Duncan T, Black C. A randomised controlled trial of a community intervention to prevent adolescent tobacco use. Tobacco Control 2000;9:24-32.
D'Onofrio 2002 {published data only}
  • Braverman MT, Moskowitz JM, D'Onofrio CN, Foster V. Project 4-health develops program to curb youth tobacco use. California Agriculture 1994;48:39-43.
  • D'Onofrio CN, Moskowitz JM, Braverman MT. Curtailing Tobacco Use Among Youth: Evaluation of Project 4 Health. Health Education Behaviour 2002;29:656-682.
De Vries 2003 {published data only}
  • Ariza C, Nebot M, Tomas Z, Gimenez E, Valmayor S, Tarilonte V, DeVries H. Longitudinal effects of the European smoking prevention framework approach (ESFA) project in Spanish adolescents. European Journal of Public Health 2008;18(5):491-7. [DOI: 10.1093/eurpub/ckn050]
  • Connelly J, Green J, Lechner L, Mittelmark MB, Rigby AS, Roberts C. The European Smoking Prevention Framework Approach (ESFA) project: Observations by Six Commentators. Health Education Research 2003;18(6):664-77. [DOI: 10.1093/her/cyg052]
  • De Vries H, Dijk F, Wetzels J, Mudde A, Kremers S, Ariza C, Vitoria PD, Fielder A, Holm K, Janssen K, Lehtovuori R, Candel M. The European Smoking prevention Framework Approach (ESFA): effects after 24 and 30 months. Health Education Research 2006;21(1):116-32. [DOI: 10.1093/her/cyh048]
  • De Vries H, Engels R, Kremers S, Wetzels J, Mudde A. Parents' and friends' smoking status as predictors of smoking onset: findings from six European countries. Health Education Research 2003;18(5):627-36. [DOI: 10.1093/her/cyg032]
  • De Vries H, Mudde A, Leijs I, Charlton A, Vartiainen E, Buijs G, Clemente MP, Storm H, Navarro AG, Nebot M, Prins T, Kremers S. The European Smoking prevention Framework Approach (ESFA): an example of integral prevention. Health Education Research 2003;18(5):611-26. [DOI: 10.1093/her/cyg031]
  • De Vries J, Mudde A, Kremers S, Wetzels J, Uiters E, Ariza C, Vitoria PD, Fielder A, Holm K, Janssen K, Lehtuvuori R, Candel M. The European Smoking Prevention Framework Approach (ESFA): short-term effects. Health Education Research 2003;18(6):649-63. [DOI: 10.1093/her/cyg033]
  • Nahit E, Fielder A, Charlton A, Povey A. Smoking behaviour in year 8 pupils: Baseline characteristics of the UK ESFA longitudinal study. International Journal of Health Promotion and Education 2003;41(1):4-13.
  • Vartiainen E, Pennanen M, Haukkala A, Dijk F, Lehtovuori R, De Vries H. The effects of a three-year smoking prevention programme in secondary schools in Helsinki. European Journal of Public Health 2007;17(3):249-56. [DOI: 10.1093/eurpub/ckl107]
Elder 2000 {published data only}
  • Elder JP, Campbell NR, Litrownik AJ, Ayala GX, Slymen DJ, Parra-Medina D, Lovato CY. Predictors of Cigarette and Alcohol Susceptibility and Use among Hispanic Migrant Adolescents. Preventive Medicine 2000;31:115-123.
  • Elder JP, Litrownik AJ, Slymen DJ, Campbell NR, Parra-Medina D, Choe S, et al. Tobacco and alcohol use-prevention program for Hispanic migrant adolescents. American Journal of Preventive Medicine 2002;23:269-75.
  • Litrownik AJ, Elder JP, Campbell NR, Ayala GX, Slymen DJ, Parra MD, et al. Evaluation of a tobacco and alcohol use prevention program for Hispanic migrant adolescents: promoting the protective factor of parent-child communication. Preventive Medicine 2000;31(2 (Pt 1)):124-33.
Gordon 1997 {published data only}
  • Gordon I, Whitear B, Guthrie D. Stopping them starting: evaluation of a community-based project to discourage teenage smoking in Cardiff. Health Education Journal 1997;46:42-50.
Gordon 2008 {published data only}
Hancock 2001 {published data only}
  • Hancock L, Sanson-Fisher R, Perkins J, Girgis A, Howley P, Schofield M. The effect of a community action intervention on adolescent smoking rates in rural Australian towns: the CART project. Cancer Action in Rural Towns. Preventive Medicine 2001;32:332-40.
Hawkins 2009 {published data only}
  • Fagan AA, Hanson K, Hawkins JD, Arthur MW. Implementing effective community-based prevention programs in the Community Youth Development Study. Youth Violence and Juvenile Justice 2008;6(3):256-78. [DOI: 10.1177/1541204008315937]
  • Hawkins JD, Oesterle S, Brown EC, Arthur MW, Abbott RD, Fagan AA, Catalano RF. Results of a Type 2 Translational Research Trial to Prevent Adolescent Drug Use and Delinquency. Archives of Pediatric and Adolescent Medicine 2009;163(9):789-98.
Klein 2009 {published data only}
Murray 1994 {published data only}
  • Murray DM, Hannan PJ. Planning for the Appropriate Analysis in School-Based Drug-Use Prevention Studies. Journal of Consulting and Clinical Psychology 1990;58(4):458-68.
  • Murray DM, Jacobs DR, Perry CL, Pallonen U, Harty KC, Griffin G, Mon ME, Hanson G. A Statewide Approach to Adoelscent Tobacco-Use Prevention: the Minnesota-Wisconsin Adolescent Tobacco-Use Research Project. Preventive Medicine 1988;17:461-74.
  • Murray DM, Perry CL, Griffin G, Harty KC, Jacobs DR, Schmid L, et al. Results from a statewide approach to adolescent tobacco use prevention. Preventive Medicine 1992;21:449-72.
  • Murray DM, Prokhorov AV, Harty KC. Effects of a Statewide Antismoking Campaign on Mass Media Messages and Smoking Beliefs. Preventive Medicine 1994;23:54-60.
  • Murray DM, Rooney BL, Hannan PJ, Peterson AV, Ary DV, Biglan A, Botvin GJ, Evans RI, Flay BR, Futterman R, Getz JG, Marek PM, Orlandi M, Pentz MA, Perry CL, Schinke SP. Intraclass Correlation among Common Measures of Adolescent Smoking: Estimates, Correlates, and Applications in Smoking Prevention Studies. American Journal of Epidemiology 1994;140(11):1038-50.
Pentz 1989 {published data only}
  • Pentz MA, Dwyer JH, Mackinnon DP, Flay BR, Hansen WB, Wang EY, Johnson CA. A multicommunity trial for primary prevention of adolescent drug abuse. Effects on drug use prevalence. JAMA 1989;261:3259-66.
Perry 1994 {published data only}
  • Perry CL, Kelder SH, Klepp K. Community-wide cardiovascular disease prevention in young people: long-term outcomes of the Class of 1989 Study. European Journal of Public Health 1994;4:188-194.
Perry 2003 {published data only}
Perry 2008 {published data only}
Piper 2000 {published data only}
  • Moberg DP. Personal communication 1999.
  • Moberg DP, Piper DL, Serlin RC, Wu J. When total randomization is impossible- nested randomization assignment. Evaluation Review 1993;17:271-91.
  • Piper DL, Moberg DP, King MJ. The Healthy for Life Project: behavioral outcomes. Journal of Primary Prevention 2000; Vol. 21:47-73.
Schinke 2000 {published data only}
Schofield 2003 {published data only}
Stevens 2002 {published data only}
  • Stevens MM, Olson AL, Gaffney CA, Tosteson TD, Mott LA, Starr P. A Pediatric, Practice-Based, Randomized Trial of Drinking and Smoking Prevention and Bicycle Helmet, Gun, and Seatbelt Safety Promotion. Pediatrics 2002;109(3):490-7.
St Pierre 1992 {published data only}
  • St Pierre TL, Kaltreider DL, Mark MM, Aikin KJ. Drug prevention in a community setting: A longitudinal study of the relative effectiveness of a 3-year primary prevention program in boys and girls clubs across the nation. American Journal of Community Psychology 1992;20:673-706.
Sussman 1998 {published data only}
Tang 1997 {published data only}
  • Tang KC, Rissel C, Bauman A, Dawes A, Porter S, Fay J, et al. Evaluation of Kickbutts - a school and community-based smoking prevention program among a sample of year 7 and 8 students. Health Promotion Journal of Australia 1997;7:122-7.
Vartiainen 1998 {published data only}
Winkleby 1993 {published data only}
Winkleby 2004 {published data only}
  • Winkleby MA, Feighery E, Dunn M, Kole S, Ahn D, Killen JD. Effects of an Advocacy Intervention to Reduce Smoking Among Teenagers. Archives of Pediatric and Adolescent Medicine 2004;158:269-75.

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要Résumé scientifique摘要
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Aguirre-Molina 1995 {published data only}
  • Aguirre-Molina M, Gorman DM. The Perth Amboy Community Partnership for Youth: Assessing its effects at the environmental and individual levels of analysis. International Quarterly of Community Health Education 1995;15(363):378.
Aldinger 2008 {published data only}
  • Aldinger C, Xin-Wei Z, Li-Qun L, Jun-Xiang G, Hai YS, Jones J. Strategies for implementing Health-Promoting Schools in a province in China. IUHPE - Promotion and Education 2008;15(1):24-9. [DOI: 10.1177/1025382307088095]
  • Aldinger C, Xin-Wei Z, Li-Qun L, Xue-Dong P, Sen-Hai Y, Jones J, Kass J. Changes in attitudes, knowledge and behavior associated with implementing a comprehensive school health program in a province of China. Health Education Research 2008;23(6):1049-67. [DOI: 10.1093/her/cyn022]
American Lung Assoc 2008 {published data only}
  • American Lung Association, Division of Public Health's Tobacco Prevention Community contract, Delaware Health Fund. Practice Notes: Strategies in Health Education; A Program of Life. Health Education & Behavior 2008;35(2):153-57. [DOI: 10.1177/1090198108315800]
Andrade e Silva 1991 {published data only}
  • Andrade e Silva MI. La Prevention du Tabagisme par la Promotion de la Sante [Smoking prevention through health promotion. A novel experience in schools of the northern region of Portugal]. Hygie 1991;10(4):26-31.
Arora 2010 {published data only}
  • Arora M, Tewari A, Tripathy V, Nazar GP, Juneja NS, Ramakrishnan L, Reddy KS. Community-based model for preventing tobacco use among disadvantaged adolescents in urban slums of India. Health Promotion International 2010;25(2):143-52.
Baudier 1991 {published data only}
  • Baudier F, Henry Y, Marchais M, Dorier J, Lombardet A, Llaona P, et al. The "Besancon smoke-free" programme. Concepts, measures and evaluation. Hygie 1991;10(4):18-25.
Berenson 2010 {published data only}
Bowen 2002 {published data only}
Brownson 1996 {published data only}
  • Brownson RC, Smith CA, Pratt M, Mack NE, Jackson-Thompson J, et al. Preventing cardiovascular disease through community-based risk reduction: the Bootheel Heart Health Project. American Journal of Public Health 1996;86:206-13.
Cain 1992 {published data only}
Campion 1994 {published data only}
Carleton 1995 {published data only}
  • Carleton RA, Lasater TM, Assaf AR, Feldman HA, McKinlay S. The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk. American Journal of Public Health 1995;85:777-85.
Charlier 2009 {published data only}
Chen 2006 {published data only}
Clarke 1993 {published data only}
Cruz 2008 {published data only}
  • Cruz GG, Ferrero MG, Coca IA, Maderuelo JA, Garcia MT. Program for the Prevention of Smoking in Secondary School Students [Programa de prevencion del tabaquismo en alumnos de ensenanza secundaria]. Archivos de Bronconeumologia 2008;45(1):16-23.
Davidson 1994 {published data only}
  • Davidson JE. Smokebusters: the experience of a Smokebusters intervention in a youth club in North-East England. Edinburgh University MSc Dissertation 1994.
  • Davidson L. Wensleydale Smokebusters Project Report. Northallerton: Northallerton Health Authority 1992.
Elder 1996 {published data only}
  • Elder JP, Edwards CC, Conway TL, Kenney E, Johnson CA, Bennett ED. Independent evaluation of the California Tobacco Education Program. Public Health Reports 1996;111:353-8.
Elder 1996b {published data only}
  • Elder JP, Perry CL, Stone EJ, Johnson CC, Yang MH, Edmundson EW, et al. Tobacco use measurement, prediction, and intervention in elementary schools in 4 states - the CATCH study. Preventive Medicine 1996;25:486-94.
Farquhar 1991 {published data only}
Fawcett 1997 {published data only}
  • Fawcett SB, Lewis RK, Paine-Andrews A, Francisco VT, Richter KP, Williams EL, et al. Evaluating community coalitions for prevention of substance abuse: the case of Project Freedom. Health Education & Behavior 1997;24:812-28.
Forster 1998 {published data only}
Frith 1997 {published data only}
  • Frith C, Roberts C, Kingdon A, Tudor-Smith C. An evaluation of the 1996 No Smoking Day in Wales. Health Education Journal 1997;56:287-95.
Harvey 1990 {published data only}
HEA 1994a {published data only}
  • Health Education Authority. Health skills for girls. London: HEA, 1994.
HEA 1994b {published data only}
  • Health Education Authority. `Hi-Energy': a final report and evaluation findings. London: HEA, 1994.
HEA 1994c {published data only}
  • Health Education Authority. Choices about health for Ashfield teenagers (CHAT). London: HEA, 1994.
Higgs 2000 {published data only}
  • Higgs PE, Edwards D, Harbin RE, Higgs PC. Evaluation of a Self-Directed Smoking Prevention and Cessation Program. Pediatric Nursing March-April 2000;26(2):150-5.
Hunkeler 1990 {published data only}
  • Hunkeler DF, Davis EM, Mc Neil B, Powell JW, Polen. Richmond quits smoking: a minority community fights for health. In: Bracht N editor(s). Health promotion at the community level. Newbury Park, CA: Sage, 1990.
Hymowitz 1995 {published data only}
  • Hymowitz N. Paterson COMMIT: a smoke-free community initiative. New Jersey Medicine 1995;92:22-4.
Jason 2010 {published data only}
Kaufman 1994 {published data only}
Lazenbatt 1997 {published data only}
  • Lazenbatt A. Protecting young people from tobacco: an evaluation of the Ulster Cancer Foundation's "Smokebusters" campaign in primary schools in Northern Ireland. Ulster Cancer Foundation; Belfast 1997.
Marin 1994 {published data only}
  • Marin BV, Perez Stable EJ, Marin G, Hauck WW. Effects of a community intervention to change smoking behavior among Hispanics. American Journal of Preventive Medicine 1994;10:340-7.
Meshack 2004 {published data only}
Morgan 1994 {published data only}
  • Morgan M, Doorley P, Hynes M, Joy S. An evaluation of a smoking prevention programme with children from disadvantaged communities. Irish Medical Journal 1994;87:56-8.
Mudde 1995 {published data only}
Nater 1985 {published data only}
  • Nater B, Junod B, Gutzwiller F, Wietlisbach V. [The influence of family environment on the evolution of tobacco consumption in 2 trial towns and 2 control towns in Switzerland]. Revue d'Épidémiologie et de Santé Publique 1985;33:90-6.
Nilsson 2006 {published data only}
O'Loughlin 1995 {published data only}
  • O'Loughlin J, Paradis G, Kishchuk N, Gray-Donald K, Renaud L, Fines P, et al. Coeur en sante St-Henri - a heart health promotion programme in Montreal, Canada: design and methods for evaluation. Journal of Epidemiology & Community Health 1995;49:495-502.
Pentz 1989B {published data only}
  • Johnson CA, Pentz MA, Weber MD, Dwyer JH, Baer N, MacKinnon DP, Hansen WB. Relative Effectiveness of Comprehensive Community Programming for Drug Abuse Prevention With High-Risk and Low-Risk Adolescents. Journal of Consulting and Clinical Psychology 1990;58(4):447-56. [DOI: 0022-006X/90]
  • MacKinnon DP, Johnson CA, Pentz MA, Dwyer JH. Mediating Mechanisms in a School-Based Drug Prevention Program: First-Year Effects of the Midwestern Prevention Project. Health Psychology 1991;10(3):164-72. [DOI: 85287-1104]
  • Pentz MA, Johnson CA, Dwyer JH, MacKinnon DM, Hansen WB, Flay BR. A Comprehensive Community Approach to Adolescent Drug Abuse Prevention: Effects on Cardiogascular Disease Risk Behaviors. Annals of Medicine 1989;21:219-22. [DOI: 10.3109/07853898909149937]
  • Pentz MA, MacKinnon DP, Dwyer JH, Wang EYI, Hansen WB, Flay BR, Johnson CA. Longitudinal Effects of the Midwestern Prevention Project on Regular and Experimental Smoking in Adolescents. Preventive Medicine 1989;18:304-21.
  • Pentz MA, MacKinnon DP, Flay BR, Hansen WB, Johnson CA, Dwyer JH. Primary Prevention of Chronic Diseases in Adolescence: Effects of the Midwestern Prevention Project on Tobacco Use. American Journal of Epidemiology 1989;130(4):713-24.
Pierce 1998 {published data only}
Pomrehn 1995 {published data only}
  • Pomrehn PR, Jones MP, Ferguson KJ, Becker SL. Tobacco use initiation in middle school children in three IOWA communities: Results of the Iowa program against smoking (I-PAS). Journal of Health Education 1995;26:92-100.
Ramirez 1988 {published data only}
Ramirez 1997 {published data only}
  • Ramirez AG, Gallion KJ, Espinoza R, McAlister A, Chalela P. Developing a media- and school-based program for substance abuse prevention among Hispanic youth: a case study of Mirame!/Look at me!. Health Education & Behavior 1997;24:603-12.
Reinert 2004A {published data only}
  • Reinert B, Carver V, Range LM. Anti-Tobacco Messages From Different Sources Make a Difference With Secondary School Students. Journal of Public Health Management Practice 2004;10(6):518-23.
Reinert 2004B {published data only}
  • Reinert B, Carver V, Range LM. Tobacco use prevention in private high schools. Quarterly of Community Health Education 2004;22(1 & 2):47-58.
Rigotti 2002 {published data only}
  • Rigotti NA, Regan S, Majchrzak NE, Knight JR, Wechsler H. Tobacco use by Massachusetts public college students: long term effect of the Massachusetts Tobacco Control Program. Tobacco Control 2002;11:ii20-4. [DOI: 10.1136/tc.11.suppl_2.ii20]
Rohrbach 1994 {published data only}
  • Rohrbach LA. Hodgson CS. Broder BI. Montgomery SB. Flay BR. Hansen WB, et al. Parental participation in drug abuse prevention: Results from the Midwestern Prevention Project. Journal of Research on Adolescence 1994;4:295-317.
Schinke 1996 {published data only}
Shea 1990 {published data only}
  • Shea S, Basch CE. A review of five major community-based cardiovascular disease prevention programs. Part I: Rationale, design, and theoretical framework. American Journal of Health Promotion 1990;4:203-13.
Shipley 1995 {published data only}
  • Shipley RH, Hartwell TD, Austin WD, Clayton AC, Stanley LC. Community stop-smoking contests in the COMMIT trial: relationship of participation to costs. Community Intervention trials. Preventive Medicine 1995;24:286-92.
Sigfusdottir 2008 {published data only}
Slater 2006 {published data only}
Smith 2008 {published data only}
Stein 1997 {published data only}
  • Stein J, Glass K, Coburn K, Sisson J, Birnkrant J, Bravo A, et al. A medical school's plan for anti-tobacco-use education in community schools and hospitals. Journal of Cancer Education 1997;12:157-60.
Stevenson 1998 {published data only}
  • Stevenson JF, McMillan B, Mitchell RE, Blanco M. Project HOPE: Altering risk and protective factors among high risk Hispanic youth and their families. Journal of Primary Prevention 1998;18:287-317.
Steyn 1997 {published data only}
  • Steyn K, Steyn M, Swanepoel AS, Jordaan PCJ, Jooste PL, Fourie JM, et al. Twelve-year results of the Coronary Risk Factor Study (CORIS). International Journal of Epidemiology 1997;26:964-71.
Tingen 2005 {published data only}
Tudor-Smith 1998 {published data only}
  • Tudor-Smith C, Nutbeam D, Moore L, Catford J. Effects of the Heartbeat Wales programme over five years on behavioural risks for cardiovascular disease: quasi-experimental comparison of results from Wales and a matched reference area. BMJ 1998;316:818-22.
van Teijlingen 1996 {published data only}
Vicary 1996 {published data only}
  • Vicary JR, Doebler MK, Bridger JC, Gurgevich EA. A community systems approach to substance abuse prevention in a rural setting. Journal of Primary Prevention 1996;16:303-18.
Wheeler 1988 {published data only}
Wickizer 1993 {published data only}
  • Wickizer TM, Von-Korff M, Cheadle A, Maeser J, Wagner EH, Pearson D, et al. Activating communities for health promotion: a process evaluation method. American Journal of Public Health 1993;83:561-7.
Wilson 2008 {published data only}
  • Wilson N, Minkler M, Dasho S, Wallerstein N, Martin AC. Getting to Social Action: the Youth Empowerment Strategies (YES!) Project. Health Promotion Practice 2008;9(4):395-403. [DOI: 10.1177/1524839906289072]
Wood 2009 {published data only}
Wu 2003 {published data only}
  • Stanton B, Cole M, Galbraith J, Li X, Pendleton S, Cottrel L, Marshall S, Wu Y, Kaljee L. Randomised Trial of a Parent Intervention: Parents Can Make a Difference in Long-term Adolescent Risk Behaviors, Perceptions, and Knowledge. Archives of Pediatric and Adolescent Medicine 2004;158:947-55.
  • Wu Y, Stanton BF, Galbraith J, Kaljee L, Cottrell L, Li X, Harris CV, D'Alessandri D, Burns JM. Sustaining and Broadening Intervention Impact: A Longitudinal Randomized Trial of 3 Adolescent Risk Reduction Approaches. Pediatrics 2003;111(1):e32-8.
Yoffe 1994 {published data only}
  • Yoffe SJ, Boren JB. Follow-up study of a field-based campaign against tobacco usage for children in grades six through eight. Texas Medicine 1994;90:71-4.

Additional references

  1. Top of page
  2. Abstract摘要Résumé scientifique摘要
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Altman 1997
Bauman 1996
BMA 2008
  • Hastings G, Angus K. Forever cool: the influence of smoking imagery on young people. British Medical Association Science and Education Department and the Board of Science, July 2008.
Brinn 2010
CART 1996a
CART 1996b
  • CART Project Team. Community action for cancer prevention: overview of the Cancer Action in Rural Towns (CART) project, Australia. Health Promotion International 1996;11:277-290.
Catalano 1996
  • Catalano RF, Kosterman R, Hawkins JD, Newcomb MD, Abbott RD. Modeling the etiology of adolescent substance use: A test of the social development model. Journal of Drug Issues 1996;26(2):429-55.
EPOC 2009
  • Cochrane EPOC Group 2009 . Cochrane EPOC Group. Cochrane Effective Practice and Organisation of Care Group.. Available from: http://www.epoc.cochrane.org (accessed 1 November 2009).
Fleming 2008
  • Fleming CB, Catalano RF, Mazza JJ, Brown EC, Haggerty KP, Harachi TW. After-school activities, misbehaviour in school, and delinquency from the end of elementary school through the beginning of high school: a test of social development model hypotheses. Journal of Early Adolescence 2008;28:277-303. [DOI: 10.1177/0272431607313589]
Gail 1992
Gupta 2008
  • Gupta PC, Asma S. Bidi Smoking and Public Health. Ministery of Health and Family Services, Government of India 2008; Vol. [accessed 03/02/2011].
GYTSC 2002
Higgins 2008
  • Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.2. Chichester (UK): The Cochrane Collaboration; John Wiley & Sons, 2008.
Mackay 2006
  • Mackay J, Eriksen M, Shafey O. The Tobacco Atlas. Second Edition. Georgia, USA: American Cancer Society, 2006. [: ISBN: 0-944235-58-1]
MMWR 2008
  • Warren CW, Jones NR, Peruga A, Chauvin J, Baptiste J, Costa de Silva V, el Awa F, Tsouros A, Rahman K, Fishburn B, Bettcher DW, Asma S. Global Youth Tobacco Surveillance. Morbidity Mortality Weekly Review - CDC 25 Jan 2008;57(SS01):1-21.
Murray 1992
Murray 1996
  • Murray DM, Moskowitz JM, Dent C. Design and analysis issues in a community-based drug-use prevention trial. American Behavioral Scientist 1996;39(7):853-67.
NHS IC 2010
  • Elizabeth Fuller, Marie Sanchez (Editors). Smoking, drinking and drug use among young people in England in 2009. www.ic.nhs.uk/pubs/sdd09fullreport: NHS Information Centre for Health and Social Care, 2010.
Rahman 2000
Rao 1992
Rooney 1996
SAMHSA 2009
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Schofield 1991
  • Schofield MJ, Redman S, Sanson-Fisher RW. A community approach to smoking prevention: a review. Behaviour Change 1991;8:17-25.
Stead 1996
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Thomas 2006
Ukoumunne 1999
  • Ukoumunne OC, Guilliford MC, Chinn S, Sterne JAC, Burney PGJ. Methods for evaluating area-wide and organisation based intervention health and health care: a systematic review. Health Technology Assessment 1999;3(5):1-108.
UMDNJ 2007
  • UMDNJ-School of Public Health. Tobacco Surveillance Data Brief: Youth Consumption of Cigarettes. http://www.state.nj.us/health/as/ctcp/documents/youth_consumption_of_cigarettes.pdf [accessed 09/07/2010] 2007; Vol. 2, issue 1.
USDHHS 1994
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Warren 2009
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Watson 2003
  • Watson CH, Polzin GM, Calafat AM, Ashley DL. Determination of the Tar, Nicotine, and Carbon Monoxide Yields in the Smoke of Bidi Cigarettes. Nicotine and Tobacco Reasearch 2003;5(5):747-53.
Wiehe 2005
  • Wiehe SE, Garrison MM, Christakis DA, Ebel BE, Rivara FP. A systematic review of school-based smoking prevention trials with long-term follow-up. Journal of Adolescent Health 2005;36(3):162-9.

References to other published versions of this review

  1. Top of page
  2. Abstract摘要Résumé scientifique摘要
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Feedback
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. Additional references
  23. References to other published versions of this review
Sowden 2000a
  • Sowden A, Arblaster L. Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews 2000, Issue 1. [DOI: 10.1002/14651858.CD001291]
Sowden 2003